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Emergentology: The Diarrhea Champion

Walker, Graham MD

doi: 10.1097/01.EEM.0000436451.07493.8e

Dr. Walker is an emergency physician at Kaiser San Francisco. He is the developer and co-creator of MDCalc, a medical calculator for clinical scores, equations, and risk stratifications, and The NNT, a number-needed-to-treat tool to communicate benefit and harm.





The emergency department liaison in my hospital for different committees and programs is called the “champion.” We've got our “stroke champion,” who tries to get us to document more swallow screens, and our “domestic violence champion,” who tries to help us navigate the reporting system and screen better. I'd like them to be called “czars” because that just sounds more intimidating, and then you get to write “czar” on your CV. But I digress.

What was really, seriously not cool (in case you're reading along, guardian angel) was being struck down with a good ol' case of Campylobacter jejuni. Now that I'm feeling better, there's honestly just too much comedic gold from my illness that I couldn't pass up the opportunity to educate you, my dear reader (Hi, Mom!). Enter, the diarrhea champion, stage left.

But first, fast fact! Did you know there's a patron saint against dysentery? I appealed while I was ill to the graces of St. Polycarp of Smyrna, instead of worshipping the porcelain gods. (He's also the protector against earaches, in case your Auralgan does not work as planned.)

Diarrhea is a common reason for a visit to the emergency department, and it's usually good form to ask about the number of stools, belly pain, fevers, recent antibiotic use, any bloody stools, sick contacts, or travel, but it's also reasonable to start including a few other questions:

  • Are you on a PPI? There certainly seems to be at least a correlation between patients on proton-pump inhibitors and the development of Clostridium difficile diarrhea. (This should also make you think twice about putting a patient with gastritis or GERD on a PPI if he hasn't tried a high-dose H2 blocker, or consider risk vs. benefit of PPIs (summary: crappy benefit) in stable, undifferentiated upper GI bleeds.)
  • Any recent admissions or contact with health care workers? Oh, your boyfriend works at a skilled nursing facility? You were admitted three months ago for a cellulitis? Like it or not, we're fomites for infection, including the diarrheal pathogens, and there also seems to be a correlation with remote hospitalizations (not necessarily in the past month) and C. diff, too.

The American College of Gastroenterology ( actually has a pretty decent guideline on evaluating and treating acute infectious diarrhea in adults as well. Like many complaints, it's our job to tease out the ones that may be harboring badness, and educate and reassure the ones that aren't. Badness red flags include fever, abdominal pain, immunocompromised patient, fecal/oral or anal sex, travel, and bloody stools.

As little as I like to recommend that our specialty do more rectal exams, it really is probably worth doing a guaiac on patients with potentially bacterial diarrhea, mostly because it's much more likely to be invasive bacterial diarrhea if you find blood, and it can help you figure out who to treat. Essentially, fever plus guaiac positive or frankly bloody/dysentery stools means you should treat. Treatment is frequently a quinolone, Bactrim, or a macrolide; the “best” antibiotic depends a bit on your culprit bug, though. Empiric treatment overall is usually a quinolone. And an important reminder: this is one area where children and adults are pretty different. Recall that there are associations (but not great evidence) with HUS/TTP from treating diarrhea in children with antibiotics. Most kids — even with bloody stools — should be getting supportive care instead of empiric antibiotics.

Ironically, the people you should empirically treat are the same ones that are recommended for a stool culture. Routine stool cultures on everybody with diarrhea, however, have an insanely low yield. You're probably wasting your lab's time and your patient's money if you don't have at least some red flags. “In two studies, stool cultures as obtained routinely in selected locations were found to have a positivity rate of 2% or less, making the cost of the test between $900 and $1200 per pathogen detected,” according to the ACG guidelines.

Speaking of patients, educating them is much more important than any antibiotic or stool culture in the world, especially if they're on day one of their diarrhea, have no red flags, and their history of present illness is “two loose stools today.”

  • Hand washing: I tell all patients and family members with diarrhea that diarrhea is one of those diseases where alcohol sanitizer doesn't work. Use good ol' soap and water. (Most people already know they wouldn't want to smear alcohol-sanitized feces around, but it's a good reminder.)
  • OTC medications: Immodium and simethicone are probably fine for most routine, no-red-flags diarrhea in adults; one study suggested a combination of the two was even better. Apparently Pepto-Bismol works even better if the diarrhea is in conjunction with nausea/vomiting (aka: gastroenteritis, food poisoning), but I really can't imagine wanting to chug the pink stuff when I'm sick to my stomach.
  • Diet: Diluted sports drinks and juices are probably fine for hydration in the developed world. (Remember, a high osmotic load of sugar may theoretically increase diarrhea volume, especially in kids, because they have less surface area to absorb it all and fewer enterocytes around, too.) Throw in a couple crackers for electrolytes, and you're probably golden. Calories are important to make new enterocytes, so the BRAT diet isn't a bad idea, either.

Next month: diarrhea goes high-tech, why you should be prescribing probiotics and Kefir to everyone, and more on C. diff.

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